Healthcare providers’ experience with the management of mental health conditions in the context of Workers’ Compensation

Abstract

BACKGROUND:

Little is known about how healthcare providers (HCPs) in Canada manage mental health claims and the return to work (RTW) of injured workers

OBJECTIVE:

To examine HCPs’ experience and challenges on the treatment of mental health conditions (MHCs) in the context of Workers’ Compensation (WC) processes and their involvement in RTW.

METHODS:

Ninety-seven interviews with HCPs (general practitioners, n = 59; allied HCPs, n = 19; specialists, n = 19) were conducted in British Columbia, Manitoba, Ontario and Newfoundland. A thematic content analysis was used to analyze interviews.

RESULTS:

HCPs reported that while RTW is extolled at virtually all costs by WC boards, they did not always see it as beneficial. Most HCPs were convinced that successful recovery and RTW depend on being aware of how mental and physical health is intertwined and treating both issues. Organizational barriers within WC processes and adversarial relationships between injured workers (IWs) and WC boards made it difficult for HCPs to adequately treat patients and facilitate RTW. Dealing with IWs’ MHCs and their emotional distress due to ‘going through WC systems’ was challenging.

CONCLUSIONS:

WC boards must identify how policies can be modified to mitigate compensation processes and RTW for WC claimants with MHC.

Keywords

Mental health claims return to work sickness absence stigma qualitative methodology

1 Introduction

1.1 Background

Mental health conditions (MHCs) are listed among the leading causes for sickness absence and workplace disability compensation in Canada and internationally [1 –5]. Many MHCs, such as depression, post-traumatic stress disorder, anxiety and adjustment disorder [6], are attributable to traumatic events, physical injuries, and stressful situations in workplace settings [7, 8]. MHCs can have an effect on an individual’s everyday activities, ability to work productively and contribute to activities away from work [9 –11]. Statistics have shown that MHCs are a substantial burden to the economy of Canada. One in five Canadians experience MHCs and about 500,000 Canadians per week are not able to work due to mental illnesses [12].

There is considerable evidence that meaningful, appropriate and sustainable work is good for health [13, 14]. Work can positively contribute to overall mental well-being and increase a worker’s quality of life and productivity [15]. Conversely, unemployment and sickness absence can harm an individual’s general health and lead to psychological morbidities [14, 16]. Studies show that return to work (RTW) is associated with lower rates of secondary MHCs and can prevent the deterioration of current MHCs [17 –19]. Roelen et al. [20] found that the longer workers with MHCs are on sickness absence, especially those experiencing depression or anxiety [21], the lower the probability of a successful RTW [22]. Individuals who successfully sustain their first RTW experience better mental health and fewer depressive symptoms [17].

1.2 Healthcare providers’ roles and responsibilities

Healthcare providers (HCPs) can play a fundamental role in the RTW of injured workers (IWs) and disability compensation processes in Workers’ Compensation (WC) systems in Canada [20]. As part of WC systems, HCPs are asked to provide information about an IW’s condition and the work-relatedness of their injury or illness. They are responsible for informing WC boards about the severity of a worker’s health problem and what type of treatment a worker needs. They are also asked to give recommendations on a worker’s ability to RTW and be involved in RTW processes [20, 23]. There are different types of HCPs who interact with IWs and WC boards, such as physiotherapists, occupational therapists, psychologists and others. Researchers suggest that general practitioners (GPs) tend to be the primary HCP who follow their patients throughout the treatment process and have the most activity in the WC system [23].

1.3 Managing mental health claims and return to work

Findings from previous studies suggest that the treatment and management of MHCs and RTW in the context of WC systems can be complex [24]. HCPs encounter challenges when dealing concurrently with physical and psychological conditions, communicating with insurers and facilitating the RTW process [20 , 25–27].

Research shows that responding to a variety of administrative requirements of WC boards can be demanding, as HCPs are asked to regularly submit documents related to IWs’ health status and care [20 , 29]. The subjectivity of MHCs can make it difficult for HCPs to fulfil their roles and responsibilities and to provide “objective” medical information on MHCs [23]. An Australian study found that GPs had difficulty predicting recovery time of MHCs and identifying what would be appropriate work for patients who appeared ready to re-start employment [30]. Findings from a study in the United Kingdom show that doctors rated workers with MHCs least likely to be ‘fit’ to RTW [31]. Other studies confirm that the RTW for workers with MHCs, especially those with depression and anxiety, can be complex [32, 33].

1.4 Legislative context – Workers’ Compensation and mental health claims in Canada

WC legislation and policy in Canada is governed provincially. There are twelve WC boards with each one setting their own regulations and entitlement rules about access to compensation benefits. Each board has decision authority for claims in their province [34, 35]. When WC systems were established in the early 20th century, a time where work mainly involved physical labor (e.g. manufacturing industries), only work-related physical injuries were compensable. However, changes in the labor market (e.g. globalizing economy, advances in technology) have shifted employment away from physically demanding jobs towards labor markets demanding new skills and knowledge (e.g. sales, science, service) [36, 37]. There has also been a gradual shift to non-standard work (including part-time jobs, multiple jobs, self-employment) that can contribute to work-related stress and have implications on the quality of work [37]. Low quality of work affects workers’ mental and physical health, as well as quality of personal and social life [37]. In Canada, there has been an increased recognition that work-related factors can contribute to the development of MHCs and that MHCs can develop as a consequence of physical injury [37].

WC systems increasingly recognize that MHCs are potential risk factors for sickness absence and lower RTW rates [38]. Yet, strict limitations on the acceptance of MH claims exist. Compared to many European social insurance systems where workers with MHCs are eligible for compensation regardless of the cause of their MHCs, compensation benefits in Canada are only provided to workers whose MHC has developed out of or during the course of employment, where work-relatedness can be proven and where a certified psychologist or psychiatrist has diagnosed a claimant’s MHC according to the latest regulations of the Diagnostic and Statistical Manual of Mental Disorders [39 –41]. For more information about policies regarding MH claims see Appendix 1.

In summary, the literature suggests that managing MHCs and the RTW of workers with MHCs is important. WC boards expect HCPs to engage in compensation processes by assisting with technical requirements and to facilitate a timely RTW. International literature suggests that HCPs can have difficulties dealing with MH claims and in identifying appropriate employment for workers with MHC [24, 30]. To our knowledge there is little research investigating how HCPs in Canada manage mental health claims and what challenges they encounter in terms of compensation and RTW processes. These challenges need to be recognized in order to provide early and appropriate treatment to workers with MHCs and to facilitate safe and timely RTW. In turn, this could reduce the economic and social burden associated with MHCs.

2 Methods

2.1 Research design

The aim of the present qualitative analysis of data from HCPs in four provinces in Canada (British Columbia, Manitoba, Ontario and Newfoundland/Labrador) was to examine HCPs’ views and challenges on the treatment of MHCs in the context of WC and their involvement in RTW of these workers. This research project was part of a larger qualitative study conducted in Canada over two years about the role of HCPs in RTW after injury or illness. This larger study consisted of three parts (i) a document analysis of materials (e.g. policies, resources, guides) aimed at HCPs about their role in RTW and in the compensation process and interviews with key informants involved in the development of these materials, (ii) interviews with case managers (adjudicators) about how they interact with HCPs and view their role in RTW, and (iii) interviews with HCPs examining their experiences with the WC system and RTW of compensation patients. As part of these interviews HCPs were asked about the management and treatment of MHCs in the context of WC. The present analysis focused specifically on this issue. An exploratory, qualitative research approach was used to get a nuanced understanding of HCPs’ experiences, approaches and strategies of interacting with WC boards and managing MHCs and RTW processes [42]. Ethical review and approval was provided by the University of Toronto, Ontario, Canada.

2.2 Recruitment

To get a diverse and ‘information rich’ sample of HCPs involved in WC systems, sampling of participants was done purposively and based on analytical grounds and emerging concepts [43, 44]. Effort was made to recruit participants from different disciplines (including GPs, specialists and allied HCPs, such as occupational therapists and psychologists), those with high and low volumes of WC patients and HCPs from rural and urban areas. HCPs were eligible if they had experience seeing at least one patient with a work injury within the last year at the time of recruitment. HCPs were recruited through clinics and health care centres. Information letters explaining the research interest and inviting HCPs to participate were distributed through medical associations, mailed, emailed, and advertised in medical newsletters and on social media (Twitter, LinkedIn). In two provinces (British Columbia and Manitoba) the WC boards also helped with some recruitment of HCPs. Those interested in being interviewed contacted the research team. HCPs were also asked to refer other HCPs who might be interested in participating in the study. Researchers predominantly interviewed GPs and specialists. As data saturation was reached, a number of allied HCPs were also interviewed, for example occupational therapists, physiotherapists and psychologists. Written informed consent to record the interview was obtained from all participants prior to the start of the interview. HCPs were provided with an honorarium of between 50 and 100 dollars as a thank you for their time.

2.3 Procedure

Interviews were conducted in British Columbia (BC), Manitoba (MB), Newfoundland (NL) and Ontario (ON), Canada, between May and November 2015. Experienced and skilled interviewers were hired in each of the four provinces to conduct one-on-one interviews with HCPs. An interview guide was developed based on the first two parts of the larger study to ensure domains relevant to this research study were discussed. Interview questions were developed collaboratively with the research team and study Advisory Committee that included representatives from a number of the WC boards, HCPs, workers and employers. These interview questions focused on two key domains: (1) HCPs’ experiences working within the WC system (e.g. Tell me about the contact you have with case managers. Are there injuries or conditions that are difficult to treat in the context of workers’ compensation? Please explain.), and (2) HCPs’ roles in RTW (e.g. What is your current role in the RTW process? What are you involved in? What do you think a HCP’s role should be?). HCPs were invited to discuss challenges they encountered and what was working well. Semi-structured interviews were conducted with a lose structure that allowed for follow up questions and probing of emergent topics. Interviews were held in person or via telephone depending on a participant’s location, work schedules and preferences. Each interview lasted between 30 and 60 minutes. All interviews were audio-recorded and transcribed verbatim.

2.4 Participants

The HCP sample included 97 HCPs. Fifty-nine GPs were interviewed (of which nine practiced internally for WC systems at the time of data collection), 19 allied HCPs, and 19 specialists. Of the 97 HCPs, 34% (n = 33) were from Ontario, 29% (n = 28) from British Columbia, 21% (n = 20) from Manitoba, and 16% (n = 16) from Newfoundland. Some participants had more than one role as they specialized in more than one domain, for example, one GP also practised as an occupational therapist. Many HCPs had experience working in different settings throughout their career, for example, as a walk-in clinic doctor and a GP. Having this diverse group of HCPs allowed for different perspectives on WC processes and RTW. Almost half of the HCPs had over 15 years of tenure, where 20% were in practice less than 5 years (Table 1).

Table 1
Type and number of healthcare providers

Type of healthcare providers Number

Total^* 97

General practitioners

   (Internal HCPs to WC boards, family doctors, walk-in clinic doctors) 59

Allied healthcare providers

   (Occupational therapists, physiotherapists, chiropractor, psychologists, registered nurses) 19

Specialists

   (Surgeons, physiatrists, anaesthesiologists, oncologists, practitioners working in occupational health and safety, rehabilitation, industrial and sports medicine) 19

Type of healthcare providers	Number
Total^*	97
General practitioners
(Internal HCPs to WC boards, family doctors, walk-in clinic doctors)	59
Allied healthcare providers
(Occupational therapists, physiotherapists, chiropractor, psychologists, registered nurses)	19
Specialists
(Surgeons, physiatrists, anaesthesiologists, oncologists, practitioners working in occupational health and safety, rehabilitation, industrial and sports medicine)	19

^*Some participants had more than one role as they were specialised in more than one domain, for example a GP also practised as an occupational therapist.

2.5 Data analysis

A thematic content analysis was used to organize data systematically and to identify, analyze and report themes across the data [45]. First, transcripts were entered into Nvivo (a computer program for qualitative data analysis) for data storage and coding of data [46]. Second, three researchers (AK, ML, ST) coded, categorized and compared themes across data [47]. Any discrepancies in coding and interpretative differences were discussed and resolved in team meetings. Part of the coding process was to replace participants’ names with numbers (e.g. P#86), to add the participants’ role (e.g. GP, allied HCP) and province where they worked. For this study, data captured in the code mental health were selectively identified for in-depth analysis. One author (LS) actively read and re-read the mental health output to familiarize herself with the data and to search for themes, meanings and patterns. Relevant sub-themes were noted in a different document for visual representation and to identify relationships between different sub-themes (e.g. RTW benefits, management of MHCs, stigma, organizational barriers to RTW). These sub-themes showed coherent patterns and a structure of analysis was built that embodied key information related to the research question [48]. Sub-themes were reviewed and discussed with another study researcher (AK) to ensure reliability and to receive additional insight into emergent findings [49]. The analysis also considered gaps and “silences” in the data – meaning, what participants left out and were not able to discuss. This constant review of data and moving back and forward between the data and developing themes led to a deeper understanding of HCPs’ experiences, challenges and strategies regarding compensation processes and RTW of workers with MHCs.

3 Results

HCPs’ experiences, responsibilities and challenges related to the management of MHCs and RTW of workers with MHCs in the context of WC systems were identified. Their roles were described as challenging because compensation processes can be complex for MH claims. HCPs suggested that going through compensation processes also had an impact on workers’ MH and, in turn, prolonged RTW. The results are described in detail in four identified themes: (I) benefits of return to work, (II) mental and physical health is intertwined, (III) difficulty managing mental health conditions under Workers’ Compensation, and (IV) difficulty with return to work.

(I) Benefits of return to work

The majority of HCPs interviewed stressed the advantages of work and RTW on an individual’s health. It was argued that work is generally beneficial in maintaining good MH because it provides workers with a routine and enhances feelings of productivity and accomplishment.

One of the most important things is for any patient’s ongoing mental health to get back to the point where they can be doing productive work and feeling like they’re contributing; accomplishing something at the end of the day is huge. (P#86, GP, MB)

HCPs felt that if workers remain off work for an extended period of time they are likely to develop psychological problems, such as depression. They noted that a person’s workplace often serves as a social network that keeps them engaged and can preserve MH. Time away from work and social contacts due to injury was thought to be harmful to IWs with underlying psychological problems or aggravate already existing MHCs. It was also thought that some IWs are likely to get used to being off work and might find it difficult to RTW, which could be harmful to their emotional and mental state.

There may be factors about staying at home, not socializing, not seeing everyone, and they’re out of the regular routine, these seem to play a part in a deterioration in vulnerable patients that have a pre-existing psychological issue. (P#95, GP, BC)

HCPs said part of their job was to regularly remind IWs of the goal of RTW with the aim of avoiding extended time off work: “We also play a big role in keeping the idea of going back to work forefront in the patient’s mind. So I like to say, so how are you doing in the progress of returning to work?” (P#51, GP, NL)

HCPs’ primary concern in terms of RTW was the safety of their patients and in some cases RTW was not considered appropriate. For instance, HCPs said more harm than good could be done if an IW was psychologically not ready to RTW but was pushed to do so. HCPs felt that pushing IWs to RTW was inappropriate and would result in poor outcomes and RTW failure.

If they’re not psychologically ready, it doesn’t matter if they’re physically ready; they’re going to keep on having symptoms. (P#113, GP, BC)

According to HCPs, recovery and RTW for workers with a MHC requires cognitive strategies, systematic planning and time. They explained that the first step in treatment is to help IWs manage self-care and return back to “normal” life. This requires gradual exposure to daily activities; helping IWs setting goals, manage their mental illness, creating a routine, etc. Many HCPs felt this had to happen before RTW was attempted:

Normally what I would do is to help them set goals; find out what is missing from their lives right now because of their mental health issues. I help them set goals around that, so they can get back to meaningful activities. A long-term goal is to get back to some sort of work. Whether it’s their position or another position that’s more suitable. But we need to start by making sure that all of their self-care, they’re setting goals around getting out of the house, activation, walking, healthy eating, and seeing their friends and family. Once people start to feel that they’re less disabled from their mental condition, once they’re on track and feeling like they’ve got more control over their lives, and those meaningful activities are back into their lives, then we start looking at readiness for return to work. (P#105, allied HCP, BC).

Most HCPs felt that in order to ensure successful RTW, MHC had to be dealt with first. One participant mentioned that even in modalities such as physiotherapy, MH should be addressed because in some cases MH needs more attention than the physical part of an injury. She explained in such cases MH could be a barrier to IWs’ readiness to start any type of therapy or rehabilitation:

I’m really believing that [mental health] needs to be addressed a lot more than even the physical portion, that’s where I get very frustrated in my work, a lot of times you just can’t reach these clients because they’re so much of the psychological system that’s not in the state of readiness to actually even do something difficult like the physical rehab. (P#119, allied HCP, BC)

(II) Mental and physical health is intertwined

HCPs believed there is a strong relationship between mental and physical health and that one affects the other. The majority of HCPs reported seeing physically injured workers develop MHCs, particularly those where there is pain, worry about re-injury or RTW conditions, and sleeplessness. HCPs explained that physical injury and MHC often go hand in hand. This strong association between physical injuries and MHCs was thought to have an impact on recovery: “Do I see people with secondary mental health concerns that influence their recovery from their primary injury? Yes, everyday. It would be very unusual for anybody to come to an injury situation and not have any effect on their mental [health].” (P#116, GP, BC).

Almost all HCPs felt that MH cannot be ignored when treating physical injuries. Looking at injuries from a bio-psychosocial perspective is necessary, however, MHCs were not always identified until the claim became complex or there was a substantial deterioration in health:

If someone strains their shoulder one would expect that to resolve within a 6–8 week timeframe and when things are going on 16 weeks, 20 weeks, we have to step back and say, “wow, let’s recognize that there’s a bio-psycho-social aspect to illness, disability and pathology” and “are there psycho-social elements here that are somehow prolonging recovery?” (P#95, GP, BC)

One HCP explained, as part of a bio-psychosocial treatment, he starts looking for any “flags” by assessing psychological issues at a three-week mark, for example by asking IWs about any sleep disturbances: “Given any injury, you know 3 or 4 weeks to kind of evolve, but definitely at the 3 week mark you start to have the spidey sense a little bit in terms of watching out for any flags that maybe other things are starting. That’s the point when I would start to maybe ask more psychosocial questions, certainly sleep, but that one gets missed all of the time.” (P#108, GP, BC)

(III) Difficulty managing mental health conditions under Workers’ Compensation

Many of the participants interviewed did not feel at ease dealing with MHCs in the context of WC systems and revealed numerous difficulties and significant barriers during the compensation and RTW processes. These related to organizational barriers, WC processes as a source of stress, the need for objective evidence, and injured worker stigma.

(i) Organizational barriers

While physical conditions and MHCs were viewed as intertwined, they were also viewed as requiring different approaches and treatments. HCPs expressed the concern that sometimes WC adjudicators adhere to regulations that might not be in the best interest of IWs’ health. One problem discussed by HCPs was that WC adjudicators often manage MHCs like physical injuries and expect recovery and RTW processes to be similar. For example, they often set timelines for recovery of injuries after which they expect IWs to RTW. As noted by several HCPs, these timelines cannot be applied to MHCs because MHCs are unpredictable in recovery. Short treatment time frames had implications for HCPs’ roles, as they had difficulties providing appropriate treatment. According to HCPs, this impeded recovery.

It depends very much on the [adjudicator] at that point how much time I have. I can get a client back to work if I’m given a bit more time than usual. If I have an [adjudicator] that’s really by the book and says “this is what we’re going to do and I’m only going to give you 12 weeks”, I’m not going to get the client back to work in 12 weeks, if he’s been off work for 2 or 3 years. (P#112, allied HCP, BC)

HCPs thought WC adjudicators should be trained on how to manage claims with a MH component. They felt adjudicators also need to start looking at injuries from a bio-psychosocial perspective rather than strictly following WC regulations better suited to physical injuries.

Sitting down, throw the physical rulebook out the window, it’s not applicable to mental health. Start from scratch. Train your people, if there’s mental health issue on the file and the physical issue, go on the mental health side because the physical person does not get it. That’s just for me, I feel really strongly about it, is I keep on saying, a bone doesn’t heal the same as the mind. (P#111, GP, BC)

Another problem expressed by HCPs was the lack of continuity of treatment or therapy for long-term patients and the change of HCPs due to discontinuation of therapy or treatment. HCPs felt the concept of building rapport with a patient during treatment and therapy was significant to recovery. However, when an IW who is making progress is ‘cut off’ compensation benefits, they lose their ‘support person’ and the rapport they have built with the treating HCPs. Participants said that the relationship between patient and HCP has to be re-build with each new treating HCP. Some HCPs mentioned that these issues would trigger mistrust in the system and they were left having to deal with IWs who are distressed by their discontinued treatment.

I don’t think it can be emphasized how important it is once a client has established a rapport with someone and they’ve gotten to a certain point, you’ve got a rapport, you’re working, you’re progressing, and then, bang, you have to start again with somebody else. [ ... ] I think one of the biggest problems that all of my clients have had, and I’m talking about the long term, 2 years or longer, clients with mental health, they all have 4-5 different psychologists because what happens is they would be approved 10 sessions and then it’s done. They go down the line, they go to someone else, and then they have to start all over again. There’s no continuity and that is also part of getting distrust in the system. (P#112, allied HCP, BC)

(ii) WC process as a source of stress

HCPs noted that the WC process is a source of stress for many IWs. From the perspective of HCPs, discontinued treatment, being cut of benefits and delays all contributed to an adversarial relationship that was counterproductive to healing. Treating HCPs felt frustrated in some cases when an IW’s MH claim was denied and they were not able to provide their patient with necessary treatment. HCPs often did not know how to further help IWs receive access to compensation benefits. This helplessness was conveyed by one GP in BC:

We have no say in that because you get patients also that get denied claims and are very upset but as a GP, other than telling them they can appeal it, there’s nothing I really do to say “okay, I’ll get your claim accepted”. No. (P#120, GP, BC)

Many HCPs noted that WC boards tend to doubt the work-relatedness of a MH claim if an IW has a history of a MHC. HCPs tended to believe, however, that a history of MHCs does not preclude workers from having a significant trigger at work causing the re-occurrence of a mental illness.

Yes, they have a long-standing history of depression, but this is an acute exacerbation we think is directly linked to this work-related event. We would still say this is a work related problem. (P#97, GP, BC)

HCPs argued that experiencing stress or frustrations related to the claim process could cause underlying MH issues to emerge. Rather than ignore these issues because they are not directly related to work, some HCPs felt that they needed to be acknowledged and dealt with as part of the recovery process.

I think that needs to be acknowledged under background history of psychosocial issues. People come to you with all sorts of history and that history might be particularly stoic behaviour, some people might be extremely anxious, some people might have depression. All of that plays a role and it’s super important for all of us to make sure we’re not prolonging their illness inadvertently because they’re going through our system. I think it’s really important to help them get on track as quickly as possible because they’re vulnerable. (P#95, GP, BC)

It was reported that MHCs are often not discovered and diagnosed early enough. HCPs suggested MH services should be a standard part of the course of treatment to prevent the development or worsening of MHCs. Psychological problems would be less of a barrier to recovery or RTW if IWs were preventatively provided with appropriate care, such as counselling. An integrated approach between psychologists, counsellors and treating physicians was thought to be beneficial for treatment and RTW.

One of the things we like to do with someone who has a chronic disorder is have a holistic approach to their treatment, a team approach, which includes, among other things, physiotherapy, the physician but also a counsellor. I think that should just be part and parcel of it, it should just be a standard part and parcel of it so the patients don’t feel like they’re being singled out. The earlier, the better, right? If we start getting to the 6–8 week mark that they’re off work, I think counsellors should be part of that right off the bat. This should be preventative; this is a standard thing we do. We know that these injuries can impact you psychologically and we just want to be there as part of that process to help you return to work. (P#113, GP, BC)

(iii) The need for objective medical evidence

HCPs explained that for IWs to receive compensation benefits, typically, there has to be objective medical proof that an injury or illness exists and is work-related. They also said that providing this evidence for mental illnesses was problematic. HCPs sometimes had difficulties answering adjudicator or case manager questions about the legitimacy and work-relatedness of IWs’ MHCs. It was not possible to verify MHCs through objective tests, “There’s no x-ray to prove it, and there’s no physical evidence, so, it’s definitely harder to speak to them (WC) in that regard.” (P#57, specialist, NL).

Convincing WC boards of the work-relatedness of MHCs was considered a challenge, especially in cases where IWs had prior MH issues. Determining how much underlying mental problems had contributed to the development of a work-related MHC was difficult: “My struggle is determining how much the patient’s disability is related to their injury and how much of it is related to an underlying psychiatric condition.” (P#46, GP, NL)

It was important for HCPs to determine answers to these questions in order for their patients to receive benefits since MHCs are only compensable if they are directly related to work or related to physical injuries caused by employment. One specialist described a situation in which he had to ‘battle’ with an adjudicator about a MH claim, which was eventually denied.

I had difficulty in persuading some of the adjudicators that this was a valid complaint. [ ... ] I was having constant battles with one adjudicator and some of the decisions that were made were quite irrational and the day she retired, she rang me up and apologized and said she was very sorry for all the decisions she’d had to make, but she was only doing her job. I think some of the adjudicators do undergo a short course as how to turn down compensation board cases. (P#127, specialist, BC)

HCPs described a degree of rigidity in terms of how certain complex conditions, like mental health, were dealt with by WC boards. In particular, the narrow scope of “evidence” that was needed by WC boards made it difficult to get a claim accepted. Denying benefits due to past MHCs also contributed to an adversarial relationship between the patient and WC board and at time the HCP and the WC board.

(iv) Stigma

Issues related to the work-relatedness and proof of MHCs sometimes led to an atmosphere of doubt and suspicion. It was noted that WC adjudicators sometimes treat IWs with MHCs and related conditions, such as chronic pain, like malingerers who are trying to take advantage of the system.

Sometimes I wonder if they [adjudicators] question if it’s a true illness or if the patient is just trying to get out of work or trying to reduce responsibilities at work. (P#57, specialist, NL).

WC wants everything to be objective, so it’s very difficult to objectively diagnosis or identify someone who is having this persistent pain. A lot of times it’s looked on as the client is either exaggerating their situation or faking it and there’s limited understanding from [WC] on it. (P#122, allied HCP, BC)

According to HCPs, having to defend one’s MHC can unintentionally cause IWs to exacerbate their ‘sick’ role. Some HCPs noted that IWs with MHCs are encouraged to show their MHC is severe or debilitating in order to be believed by their adjudicator and gain access to compensation benefits. This sometimes put HCPs in a difficult position. On the one hand, some HCPs were aware that IWs might be exaggerating symptoms because they are not being believed. On the other hand, HCPs are obliged to submit accurate assessments or medical opinion to WC boards and do not want to inappropriately advocate in favour of their patients.

You have a worker who is now in a position where they have to demonstrate that they are injured in order to be fairly supported. There may be a need on their part, naturally, to sort of emphasize how they’re hurt and a part of that may have a psychological component. I think it creates a relationship with WC where the criteria in order to meet a condition are such that workers are sometimes encouraged to pursue more of a sick role when they are injured. (P#18, specialist, ON)

When IWs were stigmatized and not believed by the WC decision makers, this often made the compensation process more adversarial. HCPs were then faced patients who had a MHC, exacerbated by difficulties they were having with the WC board. Ultimately, this delayed recovery and RTW.

(IV) Difficulty with return to work

HCPs typically felt that RTW planning was difficult when IWs were experiencing MHCs. Motivation and perception of illness were thought to have a strong influence on RTW.

A lot of clients will also have psychosocial barriers for returning to work. Depending on how big the barrier is perceived by the clients themselves and what’s identified can really vary from person to person. I would say a client who is ready to return to work and perceives themselves as able to return to work are, quote, much easier to work with, in terms of going through the steps to get back to work. (P#129, allied HCP, BC)

Some HCPs mentioned they would benefit from training on how to facilitate a successful RTW for IWs. One HCP suggested it would be useful to learn how to use techniques that involved motivational interviewing to understand a patient’s psychological situation better.

I wonder about utilising techniques with motivational interviewing or that sort of thing, to try to help get patients back to work. [ ... ] Especially when you encounter a patient who perhaps has some depression or other mental health difficulties that are contributing to their delayed return to work, if there are specific types of therapy, or motivational interviewing that could perhaps help in that area, I think that would be a cool area in training. (P#34, GP, ON)

HCPs also described that organizational factors had a significant impact on RTW. As explained above, it was perceived by HCPs that the stigma experienced by IWs led to frustration and anger. HCPs explained that most IWs have to defend themselves as a response to WC adjudicators’ judgment and distrust, which often resulted in an adversarial relationship. Expressions about how IWs felt ‘attacked by [adjudicators] and insurance companies’ and ‘bullied by [adjudicators]’ reflected the extent to which WC systems can affect IW’s MH. Those who were mistreated by WC staff experienced emotional distress. It was difficult for HCPs to manage this additional distress and prevent a worsening of the IW’s MHC. HCPs revealed that dealing with the emotional part of an IW’s injury is difficult on its own. However, when combined with frustrations and emotional distress caused by an adversarial IW-WC board relationship, it is even more challenging.

I find that often patients end up getting into this [compensation process] and they feel more attacked by [adjudicators] who are trying to look into this [MH claim]. This actually creates additional stresses. They feel it’s an adversarial relationship between them and WC a lot of times, rather than we’re in this together to help the patient and optimize their return to work. I think that creating any kind of adversarial relationship where then someone is always judging and you’re always having to defend stuff, probably in the end makes it a less successful return to work. (P#8, specialist, ON)

HCPs said that pressure by WC boards to RTW quickly could be harmful to IWs. Many HCPs expressed the concern that WC boards’ main goal is a quick RTW and blamed them for putting RTW and financial considerations first rather than recovery: “They are an insurance company, I see their goal as trying to get the patient back to their initial work level. But they are an insurance company, so the long-term plan is not to pay too much money.” (P#75, GP, MB). HCPs said they had to adhere to the regulations by WC boards by helping IWs RTW in a timely fashion although they knew this was sometimes not in the best interest of their patients.

4 Discussion

HCPs had a strong belief in the benefits of RTW for the mental and physical wellbeing of workers. Most HCPs knew that successful recovery and RTW depend on being aware of how mental and physical health is intertwined and providing treatment that addresses both of these issues. However, HCPs had difficulties managing MHCs under WC systems, as some organizational structures within WC systems made it problematic for HCPs to adequately treat their patients and facilitate RTW. Anema et al. (2006) examined the medical management of employees long-term sick listed due to MHCs and revealed that medical care and RTW strategies can be sub-optimal [50]. Work by other researchers has found that patients with MHCs are less likely to be deemed to be ‘fit’ for work and RTW processes for workers with depression and anxiety to be particularly complex [31, 33]. In this study, HCPs understood that in most cases IWs need more time to recover from their MHC than allowed by WC boards. Moreover, when IWs faced suspicion and doubt from WC decision makers related to the legitimacy of MHCs, this led to adversarial relationships and caused additional emotional distress. This made it even more challenging to treat these workers because HCPs had to deal with emotional distress in addition to the psychological and emotional part of the primary illness or injury. HCPs were sometimes not able to act in their patients’ best interest but had to treat their patients according to the regulations and expectations set by WC boards even when this seemed inappropriate from a medical perspective.

The HCPs in this study acknowledged the benefits and therapeutic influence RTW has on MH. However, while RTW is extolled at virtually all costs by WC boards, HCPs do not see it as beneficial in all circumstances. This stance is incongruent with what is being promoted by many WC boards, which is that early RTW is good for health [17–19 , 51]. From their experience, many HCPs view pushing IWs with MHCs back to work too early as counter-therapeutic. Predicting readiness to RTW for patients with MHC is difficult because readiness can depend on many individual and work-related factors. When WC boards do not consider co-morbid, pre-existing or developing MHCs, they do not have a full picture of the factors that may inhibit successful RTW. Times lines for recovery set by WC boards may not be well-suited to MHCs. Such time lines and the resulting termination of treatment or therapy are a punitive way of dealing with MHCs and may be barriers to RTW. Rather than penalizing IWs with MHCs by cutting off treatment and compensation benefits when RTW is delayed, workers whose recovery extends beyond standard recovery timelines should be provided with MH services that can help them get back to work. It is important that WC decision makers understand the challenges those with MHC may face during recovery and RTW and consider how RTW policies can be adapted for these workers. Case managers trained in the area of mental health and programs that provide additional mental health support services when claims become prolonged may benefit workers and help HCPs when they treat workers with MHCs.

Another issue raised by HCPs in this study was around the stigma that some IWs face when they develop a MHC. Previously termed the discourse of abuse (DOA) [52], negative assumptions and stigma regarding the veracity of MHCs can have negative consequences on recovery and RTW. However, stigma is not only applicable to IWs who have developed a MHC. Saunders et al. (2015) found that some IWs, in particular those with long-term work disabilities, who remain off work may be perceived as not being motivated to RTW until their re-entrance into the workplace [53]. Our study implies that absence from work can negatively affect IWs’ mental health.

Previous studies have proposed that adversarial processes affect IWs and their recovery [29 , 55]. Many IWs are victimized twice – first by their health condition and second by their negative experiences with compensation processes [29]. It is important to note that symptoms of depression (lack of motivation, difficulty getting out of bed, etc.) are similar to what some view as malingering behavior. Yet, due to the invisibility of MHCs, workers are put in the position of having to defend the veracity of their conditions and claims. HCPs noted that suspicion of malingering – common when workers have MHCs - leads to an adversarial relationship with the WC board. The problem of invisibility of MHCs was also identified by Krupa et al. [56]. The authors found that mental illness is not seen as a legitimate illness. According to their findings, workers with mental illnesses can be perceived as using the label of mental illness as a license to dodge work responsibilities. When objective proof is lacking for the presence of a MHC, HCPs sometimes need to ‘battle’ with WC boards and are exposed to lengthy, administratively demanding compensation processes. Our findings are congruent with previous research that has found that HCPs’ roles and responsibilities as demanded by WC systems are complex [24, 33]. A systematic review proposed that HCPs can be ‘healers’ by providing patient-centred care and build a trusting patient-provider relationship but at the same time they can play a harming role if they fail to fulfil technical requirements (e.g. submit medical reports with “objective” medical evidence) [28]. Our study adds to the literature by demonstrating that adversarial relationships between the IW and the WC board also have an impact on HCPs. HCPs treating IWs who are engaged in a battle with WC boards must not only deal with physical and mental conditions of the worker but also the resulting frustration and administrative difficulties that follow. It is possible that some HCPs may refuse to treat WC patients when administrative burdens become overwhelming and time consuming and relationships become adversarial.

It is important that HCPs and WC decision makers find ways to adjudicate and manage MHCs in a way that does not increase the adversity of the process. Part of this process must include greater transparency in decision-making, more training in the treatment of MHCs and about the factors that may facilitate successful RTW for those with MH problems. WC decision makers must not assume that a lack of motivation or fear of RTW is malingering. Rather, they should investigate whether there are other issues that are preventing RTW, such as difficulties with the employer, depression, or chronic pain.

The strengths of this study lie in the size and diversity of participant roles including GPs, internal medical consultants, specialists and allied HCPs. The inclusion of HCPs from four provinces in Canada adds to the quality of this study because it reflects experiences with different legislative contexts of the four jurisdictions. Qualitative interviews allowed us to explore participants’ experiences of involvement and practices from their own perspective and analyze their judgments and behaviors. Discussions with scientists who have extensive knowledge and experience in research on work and health ensured a thorough understanding and interpretation of relevant data.

This study is limited to HCPs’ experiences with WC systems and their perceptions of IWs’ emotions and experiences. IWs themselves were not included in this study. However, similarities to previous research investigating IWs’ experiences with WC systems and RTW processes suggest that organizational structures within WC systems play a role in the acceptance of MH claims and RTW [55]. Previous research has found that IWs’ develop MH issues when dealing with delayed and denied WC claims and experience failed attempts at RTW or retraining [18].

5 Conclusion

Given that going through WC processes can be stressful for workers and potentially result in a deterioration of health, MH needs to be considered when treating patients and processing claims. For preventative purposes, access to MH services should be part of the standard treatment of any injury or illness. WC boards need to identify how policies and regulations can be modified to ensure workers with MHCs have sufficient time for adequate treatment, recovery and RTW. Findings and implications for HCPs identified in this study can be of use across Canada and in other countries with similar WC systems. Further research about the interaction between WC boards and HCPs in relation to the management of MH claims and RTW of workers with MHCs would be beneficial.

Conflict of interest

None to report.

Footnotes

Appendix

Workers’ Compensation policies for mental health claims

There are twelve WC boards setting regulations and entitlement rules about access to compensation benefits. Each board has decision authority for all claims [34, 35]. Compensation claims are filed through the board where the IW is registered, where the injury occurred and/or where the worker resides [34].

Currently, all Canadian jurisdictions acknowledge a worker’s right to compensation for work-related MHCs that are attributable to acute stress [8]. Yet, strict limitations to the acceptance of MH claims exist and are framed around the causation of the MHC. Many jurisdictions limit compensation benefits to situations in which a traumatic event 1 or a series of traumatic events 2 during employment has caused a worker to immediately develop acute mental stress (e.g. a physical injury or criminal act resulted in post-traumatic stress disorder or anxiety) [40]. Few jurisdictions also provide access to compensation benefits if a physical work-related injury has resulted in the development of a secondary MHC [57]. This includes workers who developed depressive symptoms secondary to their pain, time off work or emotional distress related to dealing with financial strain [40, 58].

Because WC systems were originally set up for physical injury compensation there are still gaps in WC systems in terms of accepting MH claims that have a non-acute cause. Gradual onset MH claims (e.g. harassment) are excluded by many jurisdictions. A move towards accepting non-acute MH claims can only be observed in some jurisdictions [8]. In 2012, British Columbia amended their policy to allow workers to claim compensation for gradual onset MHCs caused by an individual’s conditions of work 3 .

Ontario: ‘An acute reaction to a sudden and unexpected traumatic event arising out of and in the course of employment.’

Northwest Territories/Nunavut’s definition of acute reaction: ‘A sudden and severe reaction by a worker to a single or a series of work-related, traumatic events that have a psychiatric or psychological response.’

British Columbia: “A worker is entitled to compensation where a mental disorder is a reaction to (i) one or more traumatic events arising out of and in the course of a worker’s employment, or (ii) a significant work-related stressor, including bullying or harassment, or a cumulative series of significant work-related stressors, arising out of and in the course of the worker’s employment.”

Acknowledgments

The authors would like to acknowledge and thank Sabrina Tonima for her assistance with study planning, data collection and coding of data.

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